1500 Claim Form Required Fields

1500 Required Fields Number and Name

Example

Notes

1. Claim Receiver Type

Other (ID)

Optum requires you check "Other"

1a. Insured's ID #

123456789

Typically the number on the member's ID card, usually 9 digits in length,
consisting of an alternate ID or the subscriber's SSN. Some member IDs
can begin with a letter (e.g., Harvard Pilgrim members).

2. Patient's Name

Patient, Mary R.

Last Name, First Name, (MI - optional)
Last name must be at least 2 characters.

3. Patients DOB
Patients SEX

01012000
M or F

Must fill in date in correct dd/mm/yyyy format

4. Insured's Name

Patient, Joe

Last Name, First Name, (MI - optional)
Last name must be at least 2 characters.

5. Patient's Address

12 Street, Town, CA, 12345

Street Address, City, State, Zip required

6. Relationship to Insured

Self, Spouse, Child, Etc.

Must choose one

11. Group Number

00732 - valid 123456 - valid 732-invalid add 00 to achieve 00732

Numeric characters 5-6 digits in length Use the member group number included on the authorization/certification letter. If the group number is less than 5 or 6 spaces, include leading zeros. Repeating numbers will be rejected. Only required for Employer Group Division

13. Payment Authorization Signature

Signature on File

Must fill in

21. Diagnosis

F43.21

At least 1 valid diagnosis code is required

24a. DOS

01012000

Must be one DOS per claim line

24b. Place of Service

11

11 = Office

24d. Procedure Code/CPT code

90806

Must be a valid CPT Code

24d. Procedure Code Modifier

HJ

Modifiers follow the CPT Code and should be included as required; the HJ modifier example is used to indicate EAP service.

24e. Diagnosis pointer

1 if only 1 diags applies or 12 if 2 diags apply or 123 if 3 diags apply or 1234 if 4 diags apply

Numeric character 1 digit
Reference diagnosis number from HCFA Field 21 - if blank we default to 1

24f. Charges

50.00

Charges for 1 unit of service

24j. Rendering Provider ID

1234567890

10-digit NPI of rendering provider

24g. Days/Units

1

1 unit per claim line detail and date of service

25. Federal TIN SSN or EIN indicator

123456789 - valid
12345678900 - valid
987654 - invalid

Must be 9-11 digits
Numeric characters only

31. Clinical Signature Date

Clinician, Sam LCSW
01012000

Name and degree or credentials of performing clinician. Last name must be at least 2 characters.
Date signed.

33. Billed By

Clinician or Clinic

Name, Address, City, State, Zip

33a. NPI

1234567890

10-digit NPI number